Strengthening Governance to Improve the Quality of Health Service
A Consensus Statement
Delivery
May 2018 This statement was produced for review by the United States Agency for International Development and developed by the USAID Health Finance and Governance with support from the USAID Applying Science to Strengthen and Improve Systems project and with participation from the Joint Learning Network and made possible by the generous support of the American people through USAID.
THE HEALTH FINANCE AND GOVERNANCE PROJECT The Health Finance and Governance (HFG) Project works to address some of the greatest challenges facing health systems today. Drawing on the latest research, the project implements strategies to help countries increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. The project also assists countries in developing robust governance systems to ensure that financial investments for health achieve their intended results. The HFG project (2012-2018) is funded by the U.S. Agency for International Development (USAID) and is led by Abt Associates in collaboration with Avenir Health, Broad Branch Associates, Development Alternatives Inc., the Johns Hopkins Bloomberg School of Public Health, Results for Development Institute, RTI International, and Training Resources Group, Inc. The project is funded under USAID cooperative agreement AID-OAA-A-1200080. To learn more, visit www.hfgproject.org
THE USAID APPLYING SCIENCE TO STRENGTHEN AND IMPROVE SYSTEMS PROJECT The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is a five-year cooperative agreement of the Office of Health Systems of the USAID Global Health Bureau designed to improve health and social services in USAID-assisted countries, strengthen their health systems, and advance the frontier of improvement science. URC’s global partners for USAID ASSIST include: EnCompass LLC, FHI 360, Harvard T. H. Chan School of Public Health, HEALTHQUAL International, Initiatives Inc., Institute for Healthcare Improvement, Johns Hopkins Center for Communications Program, WI-HER, LLC, and the World Health Organization Department of Service Delivery and Safety. The project is funded under USAID cooperative agreement AID-OAA-A-12-00101. To learn more, visit www.usaidassist.org
Submitted to: Scott Stewart, Agreement Officer Representative, HFG project Jodi Charles, Senior Health Systems Advisor Lisa Maniscalco, Agreement Officer Representative, ASSIST project Office of Health Systems Bureau of Global Health USAID/Washington
Recommended Citation: The Health Finance and Governance and USAID ASSIST Projects, May 2018. A Consensus Statement on Strengthening Governance to Improve the Quality of Health Service Delivery. Bethesda, MD: Health Finance and Governance Project, Abt Associates.
This statement was made possible by the generous support of the American people through USAID. The contents are the responsibility of Abt Associates and University Research Co., LLC and do not necessarily reflect the views of USAID or the United States Government.
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© 2017 Thommen Jose
GOOD GOVERNANCE IS CRITICAL TO ENSURING QUALITY OF HEALTH CARE Governance of quality in health care includes the stewardship and capacity to transparently and responsively direct health systems resources, performance, and stakeholder participation toward delivering quality health care. Quality health care is effective, evidence-based, efficient, accessible, timely, people-centered, equitable, and safe, continually improving health outcomes and strengthening health systems1. Governance impacts the quality of health service delivery both directly and indirectly2. Practitioners and policy makers understand this connection both intuitively and from experience, and a growing body of data supports this awareness. Specifically, a direct link has been found between higher levels of corruption; weaker institutional structures; lack of policies, regulations, use of data and non-government stakeholder engagement and lower levels of health impact associated with resources directed for health3. This knowledge, and a vision of improvement of quality through stronger governance, compel policymakers to improve policy levers and governance capacity and extend beyond improving health outcomes to the well-being of the population. Critical elements in governing for quality must be in place even in resource-constrained
http://www.who.int/maternal_child_adolescent/topics/quality-of-care/definition/en/ (accessed 7 February 2018) Cico A, Nakhimovsky S, Tarantino L, Ambrose K, Basu L, Batt S, Frescas R, Laird K, Mate K, Peterson L, Sciuto C, Stepka R. 2016. Governing quality in health care on the path to UHC: a review of 25 country experiences. Bethesda, MD: Health Finance & Governance Project, Abt Associates; and Holmberg, S., & Rothstein, B. (2011). Dying of corruption. Health Economics, Policy and Law, 6(4), 529-547. doi:10.1017/S174413311000023X 3 Makuta I, O’Hare B. (2015) “Quality of governance, public spending on health and health status in Sub Saharan Africa: a panel data regression analysis.” BMC Public Health; 15:932; 1 2
A Consensus Statement
settings to ensure and improve health care, ideally within a Universal Health Coverage (UHC) framework, ensuring affordable, accessible, quality care. Strong governance allows for faster, sustainable and more complete achievement of national and global health goals.
THE PURPOSE OF THIS CONSENSUS STATEMENT The Consensus Statement on Strengthening Governance to Improve the Quality of Health Service Delivery (“the Quality of care should be Statement”) was conceived and drafted by participants at prioritized and governance the 2nd Governing to Improve Quality workshop (August has an impactful role in 9-11, 2017) with inputs provided by a virtual community ensuring and improving health of practice (COP) for governance for quality health care, comprised of 14 country representatives from four care quality. continents, development partners and international institutions4. This Statement recognizes that in a nations’ pursuit of UHC and the Sustainable Development Goals (SDGs), quality of care should be prioritized, and that governance has an impactful role in ensuring and improving health care quality. It was developed to provide guidance to policy-makers, government ministries, the global health community, front-line health workers, and the general public on the importance, challenges and opportunities for strengthening governance to improve quality of health care. The Statement proposes a common definition of governance for quality, and describes how governance impacts quality of care directly and unambiguously. It documents the journey of governing for improvements in health outcomes and proposes priority actions to establish and improve governance strategies, actions, and roles and relationships to strengthen health quality. Finally, the Statement identifies opportunities for increased critical investments to create the enabling conditions to allow for more successful governance to improve and ensure quality of care.
STAKEHOLDERS AND ACTORS MUST BE EFFECTIVELY ENGAGED AT ALL LEVELS Stakeholders and actors must be effectively identified, engaged, and coordinated at all levels of the health system, for responsive, accountable, transparent governance structures that ensure quality health care. Sustained - ideally institutionalized - engagement of various stakeholders and actors in policy, planning, implementation (including course-correction as needed), and monitoring of quality health service delivery is essential for achieving understanding, consensus and allegiance to the goals, strategies, and actions needed to improve and maintain quality care. Stakeholders include government agencies (health and non-health ministries, sub-national government offices); service
Ferguson, S. (2018) Global Community of Practice convenes on strengthening governance for improving and assuring quality health care. Bethesda, MD: Health Finance & Governance Project, Abt Associates 4
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delivery providers (public and private sector providers); financing and regulatory actors; academic institutions; non-profits; professional councils and societies; civil society; patients; and communities. Experience and research on effective stakeholder engagement has shown that one-off engagement of stakeholders is insufficient. Rather it should be maintained over time as a periodic, repeated, possibly even continuous process, depending on the context. It is preferable to go further by being deliberate and working with many stakeholders, as opposed to moving faster but with limited engagement of one or two stakeholders5. The process of reforming and strengthening governance for quality care will differ according to the national and local context, and according to the power structures and varying interests of stakeholders. Different cultures, religions and values affect the engagement process.
All stakeholders should be as involved as possible in governance structures.
Leaders should work to ensure open communication and that understandable and relevant information is accessible to all stakeholders. An engagement process is most effective when the environment does not foster the domination of one stakeholder, but rather when all voices are heard. The voices of the vulnerable, in particular, need to be systemically and regularly captured and communicated to relevant actors. We recommend that all stakeholders be involved as is possible in governance structures, for example by establishing multi-stakeholder task forces at multiple levels to shepherd reform, policy implementation, and/or monitoring of quality care. This multi-stakeholder involvement should ensure that leaders are accountable for responding to the needs of health workers and clients, and that whistle-blowers and others who raise concerns are not punished. For governance of quality care to be effective, stakeholders should not simply be consulted in policy development and monitoring. They should also be involved and engaged in implementation and evaluation, e.g. creating technical teams that include stakeholders. Government leaders should budget and allocate both time and resources to cover the costs of engaging multiple stakeholders. Sometimes it may be necessary to actively motivate stakeholders to remain engaged, for example with incentives and including a governance role in terms of references of organizations and/or job descriptions. Where possible, establishing a means to cover at least a portion of the cost of non-government involvement could be important to achieve sustained engagement.
“Thematic Paper 3 Good governance for the health and well-being of all children and adolescents: Working together for Better Health and Well Being: Promoting Intersectoral and Interagency Action for Health and Well-being in the WHO European Region High-level Conference, “December 2016. Paris, France: World Health Organization. http://www.euro.who.int/__data/assets/pdf_file/0011/324659/Thematic-Paper-3-Governance.pdf (Accessed February 19, 2018) 5
A Consensus Statement
Š 2017 Gonzalo Guajardo/ Communication for Development Ltd.
MEASURING QUALITY WITH DATA AND APPROPRIATE INDICATORS Experts and practitioners are keenly aware that the accuracy, timeliness, availability and utility of data for measuring quality of care are essential components to effective governance of quality. Challenges related to effective use of data for decision-making include: fragmentation of data, poor data quality including insufficient validation, ensuring patient confidentiality, low capacity for data collection, reporting, analysis and use at all levels, use of data for sanctions, limited data-driven efforts to make improvements at the front-line level, and data that are not linked to quality of care. We propose that governments work to ensure that data are accessible for decision-making and increased accountability. That means data must be accurate, timely, and presented in a manner that is both understandable and accessible to decision-makers and stakeholders alike, including health facilities. We need policies at the national and institutional level that mandate data collection and use for governing. We need appropriately timed data collection, using simple, concise and functional data collection tools; integrated information systems and/or data analysis; appropriate use of information technology; improved data validation at all levels; and clear reporting and analysis. Clearly presented and accessible data should support improved feedback mechanisms for stakeholders that can serve to strengthen the governance of the health system and quality service delivery. 4
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Quality indicators should be developed and used to measure and assess inputs, processes, and outcomes, including both health outcomes and customer satisfaction. Participants in the August 2017 Governing of Quality Workshop and the Governance of Quality Community of Practice call on the global health community for a clear direction on key indicators to measure quality at the local level. Quality indicators should be specific, measurable, attainable and attributable, relevant and realistic, and time-bound (SMART). These indicators deserve special attention, and should ideally be in line with WHO’s quality dimensions6. Health indicators should be combined with financial data to understand whether resources are optimized and effectively used. This analytical process should be part of an established performance monitoring and evaluation system. Standards and indicators should be periodically reviewed for appropriateness, utility, and practicality for quality monitoring. Evaluation and monitoring should be included in planning for policy implementation, including baseline, mid-term and end-line evaluation.
Increased investment in appropriate data systems is needed to make the goal of effective use of data for strong governance of quality a reality.
Human resources capacity cannot be overlooked when strengthening the accessibility and use of data for decision-making. Human resources capacity can be strengthened by including data collection, reporting, analysis and use in job descriptions and providing adequate time and resources for these tasks. Health workers and administrators need preservice and in-service training, incentives, and increased awareness of the importance of providing and using good data for measuring quality and impact. At the institutional level, including in facilities, national governments should establish policies mandating data collection and use, and institutions and human resources must be capacitated to collect and interpret data. The national level must capacitate sub-national actors and facilities on appropriate data collection and the use of data for decision-making. We recognize this is easily said, but difficult to implement in each of our countries. Increased investment in appropriate data systems is needed to make the goal of effective use of data for strong governance of quality a reality.
WHO (2006) Quality of care: a process for making strategic choices in health systems. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. 6
A Consensus Statement
© 2017 Valeria Baeriswyl/ Communication for Development Ltd.
EXPLORE AND STRENGTHEN STRATEGIES AND TECHNIQUES FOR ASSURING AND IMPROVING QUALITY Quality improvement (QI) and quality assurance (QA) approaches are designed to meet different objectives. QA approaches often include licensing, accreditation, registration, certification, and empanelment and are usually driven by monetary and non-monetary incentives. QI approaches can be incorporated into many QA efforts, usually include capacity building activities, and can also be driven by monetary and non-monetary incentives. However, both QA and QI approaches are used and understood differently across countries. In some cases, different actors are mandated to implement different approaches, sometimes with overlapping or unclear roles and capacities, which may result in incomplete or fragmented implementation. Policy makers and health administrators, including health workers, when implementing these strategies struggle to:
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Build the capacity of actors in implementing and enforcing these quality approaches aligned with a national direction of improving quality Sustain these mechanisms for assuring or improving quality Motivate providers in maintaining activities that continuously improve quality Monitor the quality of care provided by the facilities
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These strategies and approaches are often negatively impacted by factors outside of their direct implementation such as:
The absence of community and patient voice in QA and QI approaches Absence of QI strategies from the curriculum and quality standards of medical and allied health programs Absent or weak institutional capacity to ensure and monitor quality of essential commodities and medicines Facility infrastructure and other critical input limitations Costs of QA Lack of availability of capabilities in country for assessing quality Ability of leaders to interpret QA results Connectivity to other quality disciplines including quality control and quality planning
While governments establish their own basic/minimum standards for accreditation as an approach to QA and QI, it is recommended that these standards are developed to align with international standards. Low and middle income countries (LMICs) are seeking a template or a road map for accreditation bodies to align with international standards. This guidance should ensure accreditation costs are not prohibitive to facilities and include a step-wise approach for accreditation, starting with low-hanging fruit.
It is recommended that standards are developed to align with international standards.
Country governments should document the positive and negative results and lessons learned from mechanisms used to implement, enforce, monitor and sustain QI in LMICs, including for example documenting outcomes from:
Linking sub-national government health office budgets to quality criteria, and thus penalizing offices that do not meet established quality criteria Providing monetary awards for facilities that achieve the specified quality standards, not only as a pooled monetary reward for the facility but also as an award for individual health providers Linking facility managers’ performance contracts with achieving quality standards Institutionalizing non-monetary incentives in improving quality
It is important to engage communities and patients in developing, implementing and enforcing QA and QI programs. Medical and allied health training and schools should incorporate QA, QI, quality control and planning in the curriculum and endeavor to become accredited. The Ministry of Health, and not only the Ministry of Education, should provide guidance and recommendations for accreditation standards of medical and allied health training schools.
A Consensus Statement
© 2017 Linh Pham/ Communication for Development Ltd.
LEARNING TO INFORM FUTURE DIRECTIONS We call on the global community, national governments and all stakeholders to work to ensure that best practices for governing to ensure quality in healthcare and patient safety are captured and shared within and among countries, to devote resources to understand the institutional roles and governance structures that yield the greatest sustained impact on quality, and to document innovation in this area of work. Policy-makers world-wide increasingly recognize the importance of governance to achieve and maintain quality care, particularly in pursuit of UHC. Countries are learning while doing, and there is an appetite to increase this learning not only at the local, sub-national and national levels but also across borders. Learning from implementation to inform overall national strategic direction on quality has become increasingly important. We need to devise approaches and strategies for capturing best-fit or “good” practices, including cost-effectiveness and efficiency dimensions along with access and quality. Recommended actions include:
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Develop a global learning mechanism that seeks to capture emerging lessons on the frontline of health care improvement, while driving national health systems to UHC Engage actors, such as universities and those who have research to share, who inform best-fit or good practices Fund and organize local and international conferences and meetings to share experience and knowledge
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Continue to enhance and populate the Joint Learning Network for UHC (JLN)7 and utilize quality-related platforms such as the WHO’s Learning Laboratory for Quality UHC8 to share emerging lessons and facilitate learning within and across countries Maintain and/or create COPs that bring together implementers, policy-makers, researchers and users Incorporate human-centered design into best-fit or good practices Develop and promote global and national research agendas Foster innovation by creating Centers of Excellence and Innovation to incubate ideas and create incentives to innovate like challenge grants, fellowships and awards.
This COP recognizes the important role that research can play in learning. We have devised a research agenda to capture best-fit or good practices for governing to improve the quality of health care.9 The research agenda should be a starting point for national and global stakeholders to customize and develop their own research agendas and studies. We recommend that, at the country and global levels, stakeholders be engaged in prioritization of research themes, to ensure consensus on the research questions and methods.
Global community, national governments and all stakeholders must work to ensure best practices are captured and shared within and among countries.
Operational or implementation research can be particularly useful for policy makers, especially in the context of health reform in the pursuit of UHC. The global community will benefit from a balance between qualitative and quantitative methodologies, and the effective engagement of academics and other research bodies. We call on development partners to fund research on governing quality where national budgets are limited. Research findings should be widely disseminated to further global understanding. Newly acquired evidence and knowledge should be used to inform country policies, programs and practices.
The Joint Learning Network, an innovative country-driven network of practitioners and policy makers around the globe, is committed to expanding UHC to progressively improve health outcomes in low and middle income countries. For more information, see: www.jointlearningnetwork.org 7
The WHO Global Learning Laboratory (GLL) for Quality UHC links the experiences, expertise, passion and wisdom of people across the world, representing multiple disciplines, on important issues relating to quality in the context of UHC. See: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ 8
Laird, Kelley, Lisa Tarantino, Tiernan Mennen, and Adam Koon. January 2018. Governance to Improve the Quality of Health Services: A Research Agenda. Bethesda, MD: Health Finance and Governance Project, Abt Associates. 9
A Consensus Statement
GOVERNING FOR QUALITY AND EMERGING GLOBAL HEALTH PRIORITIES This COP agrees that global health priorities include: the SDGs, the pursuit of UHC, communicable and infectious diseases, non-communicable diseases (NCDs) and other emerging infectious diseases. Strengthening governance to improve the quality of service delivery serves to support these priorities. National policies and strategies are a key driver for In an interconnected world where effective governance of quality service delivery at all disease can spread quickly, levels within the health system. Good policies and strategies account for varied differences at the sub- quality service delivery at the national level within country. They are developed frontline can help detect, prevent through consultation and engagement with and respond to health system stakeholders. They are linked with clear operational threats in a timely manner. and measurement plans, creating a strong foundation for tracking performance and implementation of quality service provision. Good strategies allow governing bodies and institutions to seek and solve problems proactively, respond to new or changing concerns of front line workers and patients, and build open communication channels for input from all stakeholders. Countries committed to providing integrated people-centered care require strong governance to ensure services are safe and effective. As health systems strive to do no harm to their beneficiaries, considerations should also include efficiency, equity and client satisfaction, along with other priority domains noted in each country. Institutional structures and mechanisms that seek to govern quality should direct financial and human resources to address quality of care and monitor progress made on health systems strengthening. The SDGs are all intimately related. To achieve the goals of SDG 3, the health sector must work with other sectors such as SDG 6 (clean water and sanitation), SDG 7 (affordable and clean energy), SDG 9 (industry, innovation and infrastructure) and SDG 17 (partnerships for the goals). Governance of quality can help progress on the SDG agenda by engaging with multiple stakeholders, including communities and patients, who have clear roles and responsibilities to improve the health status of the population. The stakeholders must share a common vision to produce needed results, guided by a country’s strategy and/or regulatory framework and policy. Such engagement and involvement with all stakeholders serves to create an environment where all parties are held accountable to some extent. In an interconnected world where disease can spread quickly, quality service delivery at the frontline can help detect, prevent and respond to health system threats in a timely manner. Directing resources at subnational level to improve and assure quality improves the functionality of the health system and guards against health emergencies.
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We call on governments, the private sector, global organizations and development partners to invest in strengthening the transparency, accountability and responsiveness of health care delivery to assure and improve quality. There are ten areas we propose for increased and sustained investment for the greatest impact on the governance of quality care.
A Consensus Statement
Effectively engage stakeholders and actors 1) Strengthening of inter-sectoral and inter-institutional communication, coordination and collaboration to improve quality care. Examples include: Ministry of Health (MOH) and Ministry of Finance alignment on resource allocation for health priorities; MOHMinistry of Education coordination and collaboration on pre-service training for quality; public health authorities and the MOH on determining health priorities; and health insurance institutes and the MOH on standards. 2) Invest in transparency and accountability mechanisms to drive behavior change for better quality services in both public and private sectors, including engaging communities and civil society as watchdogs. The explicit priority here is to reduce corruption.
Measure Quality 3) Invest in the establishment and implementation of evidence-informed national standards for quality, and pair that with monitoring and enforcing standards at the frontline. Consideration of international standards needs to be balanced with local needs and realities. 4) Invest in data collection, management, and usability across sectors and institutions and within health institutions. Patient feedback mechanisms should be among these investments in data collection and sharing.
Strengthen mechanisms for improvement and assurance 5) Invest in legal frameworks that support quality health care. 6) Develop health service delivery systems to fit local contexts for QI and QA.
Research and share learning 7) Invest in research and evidence generation about governing for quality of care. In order to prioritize scarce resources, research is needed to understand the most impactful investments in governance for quality improvement and assurance approaches. We have developed a preliminary research agenda to use to guide prioritization. 8) Invest in centers of innovation for quality. This can be a low cost initiative that can be high value.10
For an example of the types of resources a center of innovation can generate see the US Department of Health and Human Services: https://innovations.ahrq.gov/ (accessed May 1, 2018) 10
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Strengthening Governance to Improve the Quality of Health Service Delivery 9) Continue to invest in global learning and lesson sharing among nations on this important topic through a community of practice, virtual exchanges and learning labs, and in-person exchanges.
Develop health governance capacity 10) Last but not least, increase institutional capacity building for key health institutions at national and sub-national levels related to governance. This includes adequate staff levels, training, processes and resources for ministries of health, national health insurance institutes, QA agencies, facilities, and other quality actors.